Colorectal cancer screening and surveillance practices by primary care physicians: results of a national survey

OBJECTIVE

Screening for colorectal cancer reduces its morbidity and mortality and is cost-effective. Screening is usually the responsibility of primary care physicians who may be unsure about its implementation. We aimed to assess primary care physicians' knowledge and practice regarding colorectal cancer screening, and to compare their responses with those of three national experts and with published guidelines.

METHODS

We mailed a postal questionnaire to 2,310 primary care physicians regarding demographics, nature of practice, use of screening tests, and six hypothetical patients who may have been candidates for screening or surveillance. We used published national guidelines and the collective opinions of the three external experts as the so-called "gold standard."

RESULTS

Of all respondents, 85.1% offered colorectal cancer screening. Most used suitable tests, starting at an appropriate age; 49.8% continued screening indefinitely irrespective of patients' age and 43.6% performed fecal occult blood testing without appropriate dietary advice to patients. Also, respondents frequently performed this test for inappropriate indications. Only 51.8% would follow a positive fecal occult blood test with colonoscopy.

CONCLUSIONS

Colorectal cancer screening practices by primary care physicians vary considerably from those recommended. Many offer screening to individuals in whom it is not appropriate, and continue it into advanced age. Frequent, inappropriate use of fecal occult blood tests will produce many false positives. Primary care physicians often do not appropriately follow a positive test. Further educational efforts are needed in an attempt to improve practice and further reduce the morbidity and mortality from colorectal cancer.

Evaluation of patch test in identification of causative agent in drug rashes due to antiepileptics

Patch test was evaluated for the identification of causative agent in cutaneous eruptions due to antiepileptics. Patch tests were carried out in twenty patients and ten controls with carbamazepine, phenytoin sodium, phenobarbitone and sodium valproate. Sodium valproate was found tobe irritant in 1 and 5% concentration and further dilution is recommended for patch testing. Patch test was positive in 14 (70%) patients and in 7 with suspected drug alone, and remaining 7 were positive with more than one antiepileptic drug. We recommended patch test for identification of causative drug in rashes due to antiepileptics.

Childhood trichobezoar

Two cases of trichobezoar with unusual presentation in rural female children are described. The first one in a healthy asymptomatic child with no abnormal psychological behaviour and other one in an emotionally disturbed child with history of trichotillomania. Both were treated surgically with no recurrence. A physical sign of indentibility is discussed and literature is also reviewed.

Transforming growth factor- 1 hyperexpression in African-American hypertensives: A novel mediator of hypertension and/or target organ damage

Hypertension, a remediable risk factor for stroke, cardiovascular disease, and renal failure, affects 50 million individuals in the United States alone. African Americans (blacks) have a higher incidence and prevalence of hypertension and hypertension-associated target organ damage compared with Caucasian Americans (whites). Herein, we explored the hypotheses that transforming growth factor-beta(1) (TGF-beta(1)) is hyperexpressed in hypertensives compared with normotensives and that TGF-beta(1) overexpression is more frequent in blacks compared with whites. These hypotheses were stimulated by our recent demonstration that TGF-beta(1) is hyperexpressed in blacks with end-stage renal disease compared with white end-stage renal disease patients and by the biological attributes of TGF-beta(1), which include induction of endothelin-1 expression, stimulation of renin release, and promotion of vascular and renal disease when TGF-beta(1) is produced in excess. TGF-beta(1) profiles were determined in black and white hypertensive subjects and normotensive controls and included circulating protein concentrations, mRNA steady-state levels, and codon 10 genotype. Our investigation demonstrated that TGF-beta(1) protein levels are highest in black hypertensives, and TGF-beta(1) protein as well as TGF-beta(1) mRNA levels are higher in hypertensives compared with normotensives. The proline allele at codon 10 (Pro(10)) was more frequent in blacks compared with whites, and its presence was associated with higher levels of TGF-beta(1) mRNA and protein. Our findings support the idea that TGF-beta(1) hyperexpression is a risk factor for hypertension and hypertensive complications and provides a mechanism for the excess burden of hypertension in blacks.

Probing the circadian oscillator of a mammal by two-pulse perturbations

When organisms are maintained under constant conditions of light and temperature, their endogenous circadian rhythms free run, manifesting their intrinsic period. The phases of these free-running rhythms can be shifted by stimuli of light, temperature, and drugs. The change from one free-running steady state to another following a perturbation often involves several transient cycles (cycles of free-running rhythm drifting slowly to catch up with the postperturbation steady state). Although the investigation of oscillator kinetics in circadian rhythms of both insects and mammals has revealed that the circadian pacemaker phase shifts instantaneously, the phenomenon of transient cycles has remained an enigma. We probed the phases of the transient cycles in the locomotor activity rhythm of the field mouse Mus booduga, evoked by a single light pulse (LP), using LPs at critically timed phases. The results of our experiments indicate that the transient cycles generated during transition from one steady state to another steady state do not represent the state of the circadian pacemaker (basic oscillator) controlling the locomotor activity rhythm in Mus booduga.

Transport of Ca2+ from sarcoplasmic reticulum to mitochondria in rat ventricular myocytes

Studies with electron microscopy have shown that sarcoplasmic reticulum (SR) and mitochondria locate close to each other in cardiac muscle cells. We investigated the hypothesis that this proximity results in a transient exposure of mitochondrial Ca2+ uniporter (CaUP) to high concentrations of Ca2+ following Ca2+ release from the SR and thus an influx of Ca2+ into mitochondria. Single ventricular myocytes of rat were skinned by exposing them to a physiological solution containing saponin (0.2 mg/ml). Cytosolic Ca2+ concentration ([Ca2+]c) and mitochondrial Ca2+ concentration ([Ca2+]m) were measured with fura-2 and rhod2, respectively. Application of caffeine (10 mM) induced a concomitant increase in [Ca2+]c and [Ca2+]m. Ruthenium red, at concentrations that block CaUP but not SR release, diminished the caffeine-induced increase in [Ca2+]m but not [Ca2+]c. In the presence of 1 mM BAPTA, a Ca2+ chelator, the caffeine-induced increase in [Ca2+]m was reduced substantially less than [Ca2+]c. Moreover, inhibition of SR Ca2+ pump with two different concentrations of thapsigargin caused an increase in [Ca2+]m, which was related to the rate of [Ca2+]c increase. Finally, electron microscopy showed that sites of junctions between SR and T tubules from which Ca2+ is released, or Ca2+ release units, CRUs, are preferentially located in close proximity to mitochondria. The distance between individual SR Ca2+ release channels (feet or ryanodine receptors) is very short, ranging between approximately 37 and 270 nm. These results are consistent with the idea that there is a preferential coupling of Ca2+ transport from SR to mitochondria in cardiac muscle cells, because of their structural proximity.

Ultrasound-assisted direct percutaneous endoscopic jejunostomy (DPEJ) tube placement

Direct percutaneous endoscopic jejunostomy (DPEJ) is an effective method of enteral feeding. However, failure rates with this procedure remain high due to various technical problems. We describe a case where modifications in the technique and ultrasound guidance assisted in a difficult DPEJ placement. This technique has the potential to improve the success rate of this procedure in selected cases.

Probing the circadian pacemaker of a mouse using two light pulses

In two separate sets of experiments, the phases of the locomotor activity rhythm of the nocturnal field mouse Mus booduga were probed using two light pulses (LPs). In the first set of experiments, the circadian pacemaker underlying the locomotor activity rhythm was perturbed at circadian time 14 (CT 14) using a resetting light pulse LP1 of 1000 lux intensity and 15 min duration. The phases of the resetting pacemaker were then probed at all even CTs between CT 16 and CT 14 using a PRC probing light pulse LP2 of equal strength. The "LP2 PRC" thus obtained was then compared with the single light pulse PRC in terms of the area under delay (D) and advance (A) zones of the PRCs. The time course and waveform of the two LP PRCs suggest that the LP2 PRC resembled the single LP PRC, displaced by 2 h toward the right. The LP1 PRC had smaller D compared to the single LP PRC (p = 0.007), whereas both the PRCs had A of equal magnitude (p = 0.23). This suggests that the pacemaker phase shifts rapidly after LP perturbations. In the second set of experiments, the LP1 was administered at CT 14. The phase of the pacemaker was then perturbed on day 1 (next cycle after LP1) either 2 h after activity onset (at ca. CT 14 of the transient cycle) or 8 h after activity onset (at ca. CT 20 of the transient cycle) using an LP2 of equal strength. It was observed that the steady-state phase shifts evoked by positioning an LP2, 2 h after activity onset, were positively correlated with the phase shifts observed on day 1. The steady-state phase shifts observed, when the LP2 was positioned, 8 h after activity onset, were negatively correlated with the phase shifts observed on day 1. These results suggest that the transient cycles do not mirror the state of the pacemaker oscillator.

Growth inhibitory and antifeedant activity of extracts from Melia dubia to Spodoptera litura and Helicoverpa armigera larvae

The growth inhibitory activity and deterrency of Melia dubia (Meliaceae) extracts to Spodoptera litura and Helicoverpa armigera were investigated. Artificial diet bioassays using neonate larvae of both S. litura and H. armigera indicated that dichloroethane (DCE) and methanol (Me) extracts of M. dubia inhibited growth in a dose dependent manner. DCE and Me-5II fractions also resulted in 50% deterrency at concentrations of 22.5 and 16.8 micrograms/cm2 respectively against S. litura larvae in a leaf disc-choice test. The DCE-5 fraction was found to be more toxic to larvae (LC50 of 0.65%) than the Me-5II (LC50 of 0.8%), 72 hr after topical application. Both fractions lack contact toxicity, but the deterrent effect persisted for at least 60 hr under laboratory conditions. Although salannin was isolated from the DCE fraction to show antifeedant activity, the physico-chemical characteristics of the active fractions DCE-5 and Me-5II were not identical with either salannin or azadirachtin.

Comparison of 24-hour intragastric pH using four liquid formulations of lansoprazole and omeprazole

The results of previous studies evaluating the effect of four liquid formulations of proton-pump inhibitors on 24-hour intragastric pH are described. Patients with a gastrostomy who were resident in a Veterans Affairs medical center or its affiliated nursing home were eligible for enrollment in one of four open-label studies in which each patient served as his own control. Patients underwent 24-hour intragastric pH studies before and after receiving seven consecutive days of one of the following liquid formulations of a proton-pump inhibitor administered once daily: omeprazole granules 20 mg in orange juice, lansoprazole granules 30 mg in orange juice, simplified omeprazole suspension 20 mg, and simplified lansoprazole suspension 30 mg. The suspensions were prepared with 10 mL of 8.4% sodium bicarbonate solution. Mean intragastric pH was measured, as was the time pH stayed above 3.0 and 4.0 during the 24-hour period. Six to 14 patients participated in each study. The mean posttreatment pH was 4.9+/-0.8, 4.7+/-0.6, 4.1+/-1.5, and 5.1+/-1.1 for omeprazole granules in orange juice, lansoprazole granules in orange juice, simplified omeprazole suspension, and simplified lansoprazole suspension, respectively. Both drugs in orange juice maintained pH above 4.0 longer than 14 hours and above 3.0 for close to 20 hours, which are the levels deemed optimal for healing erosive esophagitis and duodenal ulcers, respectively. Simplified lansoprazole suspension maintained pH above those thresholds for the optimal times, but simplified omeprazole suspension did not (20 and 15 hr above 3.0, 17 and 12 hr above 4.0 for lansoprazole and omeprazole, respectively). Further development of liquid formulations of proton-pump inhibitors may have important implications for the treatment of acid-related diseases in patients, including children, who are unable to swallow capsules.

A survey of gastroenterologists' perceptions and practices related to Helicobacter pylori infection

OBJECTIVE

The aim of this study was to assess the current practice of gastroenterologists in the United States concerning Helicobacter pylori (H. pylori) infection.

METHODS

We mailed a structured questionnaire to 1000 gastroenterologists chosen at random from a national database. We asked about personal and practice demographics and practices relating to testing for, and treating, H. pylori infection.

RESULTS

A total of 922 questionnaires were delivered, from which we received 286 responses (31%). Respondents used many different tests for H. pylori infection, but only 10% each had used either the 13C- or 14C-urea breath test. Testing for H. pylori infection was usually for appropriate reasons, although 21% indicated that they might not treat a patient with a positive test result. Different multiple treatment regimens were used; the most frequent were combinations of a proton pump inhibitor, clarithromycin, and either amoxicillin or metronidazole. Estimates of the prevalence of antibiotic resistance were highly variable and often inaccurate. Most respondents would not check asymptomatic individuals for the infection; however, in the absence of symptoms, 38% would personally undergo testing and treatment if positive.

CONCLUSIONS

Gastroenterologists usually test for H. pylori infection in appropriate conditions, but may not always treat the infection based on a positive test result. Most use efficacious regimens to treat the infection although many have inaccurate information on resistance rates, which may adversely influence prescribing. Many would have testing and, if positive, treatment in the absence of symptoms or a specific diagnosis, but do not recommend this for their patients.

Metaanalysis of randomized controlled trials of endoscopic retrograde cholangiography and endoscopic sphincterotomy for the treatment of acute biliary pancreatitis

OBJECTIVE

Endoscopic retrograde cholangiography with endoscopic sphincterotomy (ERC+ES) has been advocated for the management of acute biliary pancreatitis. However, it is also viewed as dangerous. Our objective was to review published randomized, controlled trials (RCTs) of ERC+ES in patients with acute biliary pancreatitis and, by metaanalysis, to estimate the overall efficacy and safety of this approach.

METHODS

We performed a fully recursive literature search for published RCTs of ERC+ES in gallstone-related acute pancreatitis. RCTs were pooled. Individual and overall mortality and complication rates were calculated, together with their 95% confidence intervals (CI), absolute risk reduction (ARR), relative risk reduction (RRR), and numbers needed to treat (NNT) for avoidance of complications or death.

RESULTS

Four published RCTs had a numerically lower complication rate, and three had a numerically lower mortality rate, in the treated groups than in controls. After pooling, there were 460 treated patients and 374 controls. Complications occurred in 115 (25.0%) treated patients and 143 (38.2%) controls (z = 4.10; p < 0.001). Twenty-four treated patients (5.2%) and 34 controls (9.1%) died (z = 2.15; p < 0.05). ERC+ES had a 34.6% RRR for complications and a 42.9% RRR for death; ARR for complications and death was 13.2% (95% CI: 6.9-19.5%) and 3.9% (95% CI: 0.35-7.45%), respectively. The NNT for avoidance of complications and death was 7.6 and 25.6, respectively.

CONCLUSIONS

ERC+ES reduces morbidity and mortality in patients with acute biliary pancreatitis. Treating 26 such patients with ERC+ES is predicted to save one life.

Macular lesions in leprosy: a clinical, bacteriological and histopathological study

Among 150 untreated patients of leprosy, 19 had only macular lesions; three were of the indeterminate type, and eight each were of the tuberculoid and the borderline types, according to the Indian Association of Leprologists (IAL, 1981) classification. The clinical, bacteriological, and histopathological parameters of these 19 patients were studied both before and after six months of WHO Multi Drug Therapy (MDT/1982). A single macule was present in seven (36.84%) patients. In twelve (63.16%), two or more were seen. In eighteen (94.74%), one or more peripheral nerves were enlarged. The size of the macules varied from 5 to 15 cm, and there were no changes seen even after treatment. In most (94.74%) of the patients, the macules were hypopigmented. The surfaces were rough and dry in seven (36.84%) but smooth in the other twelve (63.16%). The margins were well defined in the seven (36.84%) patients with single macules but ill defined in the other twelve (63.16%). After six months of antileprosy treatment, the single macules showed some resolution. Slit skin smear examination was negative in all cases before and after treatment. Clinico-histopathological correlations were seen in only six (31.58%) patients; the clinical diagnoses were indeterminate and tuberculoid leprosy in three (15.79%) patients each. In the indeterminate group, the clinico-histopathological correlation was 100%; it was 37.50% in the tuberculoid group. There were no correlations between the clinical and histopathological parameters in thirteen (68.42%) cases. After six months of treatment, the histopathology became nonspecific in all patients. The lepromin test was positive in six (31.58%) patients; four were of the tuberculoid group and one each from the indeterminate and borderline leprosy groups. Hence, although macular lesions can be seen throughout the leprosy spectrum, it is difficult to correlate their clinical, bacteriological and histopathological parameters.

Persistence of eclosion rhythm in Drosophila melanogaster after 600 generations in an aperiodic environment

The ubiquity of circadian rhythms suggests that they have an intrinsic adaptive value (Ouyang et al. 1998; Ronneberg and Foster 1997). Some experiments have shown that organisms have enhanced longevity, development time or growth rates when maintained in environments whose periodicity closely matches their endogenous period (Aschoff et al. 1971; Highkin and Hanson 1954; Hillman 1956; Pittendrigh and Minis 1972; Went 1960). So far there has been no experimental evidence to show that circadian rhythms per se (i.e. periodicity itself, as opposed to phasing properties of a rhythm) confer a fitness advantage. We show that the circadian eclosion rhythm persists in a population of the fruitfly Drosophila melanogaster maintained in constant conditions of light, temperature, and humidity for over 600 generations. The results suggest that even in the absence of any environmental cycle there exists some intrinsic fitness value of circadian rhythms.

Twice weekly 5 mg dexamethasone oral pulse in the treatment of extensive alopecia areata

Thirty patients (20 males, 10 females) with widespread alopecia areata (25 extensive alopecia areata, 5 alopecia areata) for a mean period of 4.2 years were included in the study. All patients above 12 years were administered 5 mg dexamethasone oral pulse on two consecutive days every week. Three children (< 12 years) received 2.5 mg to 3.5 mg dexamethasone oral biweekly pulse. Patients who had received treatment for a minimum period of 12 weeks were evaluated for terminal hair growth. Complete to excellent (75-95%) hair growth was observed in 16 (63.3%) patients. Growth was good (50-74%) in 2 cases and poor (< 50%) in 3 (10%) cases. Six (20%) patients has no growth of terminal hair. Complete to excellent growth of hair was obtained after a mean period of 5.35 months (range 3-10 months). Relapse occurred in one case each after three and six months but hair regrew with re-treatment. Side effects of corticosteriods were frequent, seen in 8 (26.6%) patients, but were mild. In only one case, treatment had to be discontinued. We propose that twice weekly 5 mg dexamethasone oral pulse for six months may be considered as one of the modalities in the treatment of extensive long standing alopecia areata.

Presence of M. leprae in tissues in slit skin smear negative multibacillary (MB) patients after WHO-MBR

This study looked for M. leprae in the lymph node, nerve and skin of multibacillary (MB) leprosy patients who become slit skin smear negative after the completion of WHO-MBR. Twenty-five WHO-MBR-treated multibacillary leprosy patients were studied; borderline lepromatous (BL) leprosy (n = 11) and lepromatous (LL) leprosy (n = 14)). Fifteen patients had reaction (erythema nodosum leprosum 11, upgrading reaction 4) either at presentation or during therapy. All patients attained slit skin smear negativity after WHO-MBR (range 24-39 months. Sixteen (64%) patients with multibacillary leprosy showed fragmented bacilli in skin and nerve biopsy or lymph node aspirates after WHO-MBR. Lymph node aspirates alone revealed M. leprae in seven patients, followed by nerve in two and skin in one patient. Four cases showed M. leprae at all sites followed by nerve and skin or lymph node in one case each. A pretreatment bacteriological index (BI) of 4+ or more was significantly associated with the presence of M. leprae at the end of treatment. Also, significantly more lymph node aspirates contained M. leprae in comparison with nerve or skin biopsies. All seven cases in whom treatment was extended beyond 24 months showed M. leprae in tissues even after attaining slit smear negativity. In conclusion, M. leprae persist in tissues after 2 years of WHO-MBR and patients with an initial BI of 4+ or more need to be closely followed up after stopping MDT.

Semi-automated fluorogenic PCR assays (TaqMan) forrapid detection of Escherichia coli O157:H7 and other shiga toxigenic E. coli

Semi-automated detection of Enterohaemorrhagic Escherichia coli (EHEC) O157:H7 and non-O157:H7 Shiga toxin-producing E. coli (STEC) was achieved using fluorogenic polymerase chain reaction (PCR). These PCR assays were designed to amplify 80, 120 and 150 bp regions of virulence genes stx1, stx2 and eaeA, respectively, using specific primers. The fluorogenic probes were used for specific detection of amplified products of the stx1 and stx2 genes of STEC, and the eaeA gene of EHEC O157:H7. For multiplex PCR assay, the three sets of primers and fluorogenic probes were included in one reaction to simultaneously amplify and detect any of the three targeted virulence genes. In non-multiplex PCR assay, each of the three virulence genes was amplified and detected in independent reactions. The specificity of these assays was evaluated using suspensions of STEC and other bacterial species lacking stx1, stx2 and eaeA. The multiplex assay detected all STEC harbouring any combination of three virulence genes. Three non-multiplex PCR reactions identified types of Shiga toxin genes carried by a STEC and identified STEC as either EHEC O157:H7 or non-O157:H7 STEC. Sensitivity limits of these assays in beef and faeces inoculated with EHEC O157:H7 were 5.8 to 580 cfu and 1.2 to 1200 cfu, respectively. These assays can be completed within 8-10 h when performed simultaneously or within 13 h if the multiplex assay is used as an initial screen for detecting STEC and the non-multiplex assay is used for subsequent detection of stx1 and stx2 of STEC and eaeA of EHEC O157:H7

The effects on intragastric acidity of per-gastrostomy administration of an alkaline suspension of omeprazole

BACKGROUND

It may be difficult to administer proton pump inhibitors via gastrostomy. Previous studies have examined the effect of intact proton pump inhibitor granules in orange juice. This study examined the effect of an alkaline suspension of omeprazole (simplified omeprazole suspension (SOS)) on 24-h intragastric acidity.

METHODS

Six men with an established gastrostomy had a baseline 24-h intragastric pH study using methodology we have previously described. They then received 20 mg SOS o.d. for 7 days and had a repeat pH study at the end of this period. Four of the patients then received 20 mg SOS with 30 cc of liquid antacid (Mylanta) per gastrostomy o.d. for a further 7 days and then underwent a third pH study.

RESULTS

SOS raised mean pH from 2.2 to 4.1. Intragastric pH was above 3, 4 and 5 for 35, 28 and 17% of the 24-h period at baseline, respectively; corresponding values after SOS were 63, 51 and 39%, respectively. Addition of liquid antacid to SOS did not further increase its pH-controlling effect.

CONCLUSIONS

We found a statistically significant effect of o.d. SOS on intragastric pH when administered via gastrostomy. We found no additional benefit of administering SOS with liquid antacid.

Rapid report: a novel technique for quantitative measurement of free Ca2+ concentration in rat heart mitochondria

1. The free mitochondrial Ca2+ concentration ([Ca2+]m) in rat heart mitochondria was measured quantitatively by loading the mitochondria with fura-2 and then injecting them into Xenopus laevis oocytes. 2. When oocytes were incubated with a physiological solution, the free cytosolic Ca2+ concentration ([Ca2+]c) in the oocytes was 82 +/- 11 nM (n = 20, mean +/- s.e.m.) and the [Ca2+]m of the injected rat heart mitochondria was 116 +/- 10 nM (n = 18, mean +/- s.e.m.). 3. Inhibition of the oocyte endoplasmic reticular Ca2+-ATPase with thapsigargin produced a transient increase in averaged [Ca2+]c at sub-micromolar concentrations. 4. Injection of cardiac mitochondria blunted the peak and prolonged the duration of thapsigargin-induced [Ca2+]c transients as a result of Ca2+ sequestration by the cardiac mitochondria. 5. These results demonstrate that the present technique provides a new approach for studying [Ca2+]m regulation quantitatively under physiological environments. Furthermore, it clearly shows that cardiac mitochondria can modify the shape of thapsigargin-induced cytosolic Ca2+ pulses in Xenopus oocytes.

Inhibition of apoptosis by ionomycin and zinc in peripheral blood mononuclear cells (PBMC) of leprosy patients

PBMC from tuberculoid (BT/TT) and lepromatous leprosy (BL/LL) leprosy patients showed spontaneous apoptosis when cultured in the absence of mitogen for 24 h, which was inhibited by anti-tumour necrosis factor-alpha (TNF-alpha) antibodies. Apoptosis was also inhibited by ionomycin and zinc, which also increased IL-2 and decreased TNF-alpha production. The increase in IL-2 production suggests a mechanism whereby dietary supplements with zinc might alter the cell-mediated immunity response in leprosy patients.